Procedural Sedation in Children and Young People in the Emergency Department

Publication: 07/12/2011  
Next review: 03/07/2023  
Clinical Guideline
ID: 2774 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Procedural Sedation In Children And Young People In The Emergency Department

This guideline describes the standards for the safe provision of sedation for children and younger people by Emergency Medicine Consultants in the Emergency Department (ED)

The document has been reviewed by Dr Roger Henderson on 5/5/2020. The guideline is an update to the previous guideline updated 30/08/2013. This brings the guideline into line with current RCEM guidelines on paediatric sedation. The major change is the move away from IM ketamine to IV ketamine for procedural sedation in children. It has been recognized that whilst IV access has always been seen as a minimum standard for adults, this has not been the case for children. Whilst the use of IM ketamine is still recognized as a pragmatic option when used by an experienced senior decision maker, clinicians should be mindful of the perceived safety benefits of having IV access from the start of the procedure to mitigate a rare adverse event. IM ketamine has a higher risk of emesis and a longer recovery time. IV access also facilitates repeat dosing for longer procedures.
The amended guideline also includes addition information on the management of complications and severe Emergence Phenomena rarely encountered when performing procedural sedation in Children.

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Procedural sedation is a common practice in the ED. The aims are to relieve anxiety, reduce pain, facilitate a procedure and provide amnesia. Sedation can produce a continuum of states, ranging from minimal sedation (anxiolysis) through to general anaesthesia. This guideline specifically applies to dissociative techniques using ketamine, moderate sedation (i.e. “conscious sedation”) and deep sedation. The drugs used can produce cardiovascular and respiratory complications.
The introduction of a ketamine pathway into the ED will have benefits for parents and their children as it will avoid an admission and a wait for an Emergency theatre. There are also wider benefits to the health economy as ED sedation has been demonstrated to save ~£614 per case compared to admission for theatre [1]. This is consistent with the aims of the QIPP  agenda. The use of sedation in the ED has been evaluated by NICE and its use recommended both to improve care and greater cost effective utilisation of resources [2]. The American College of Emergency Physicians have also recently published an evidence based clinical practice guideline setting the standards for ketamine administration in the ED [3].The Royal College of Emergency Medicine has also produced a “Best Practice Guideline” for ketamine procedural sedation for children in the emergency department [4].
Use of a standard protocol and knowledge of the drugs involved are vital to minimize the potential risks.

It is not acceptable for single operators to be sedating and performing a procedure in the ED. The doctor supervising sedation should be familiar with this document and trained to recognise and have the skills to deal with potential complications.

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  1. Preparing for sedation
    1. Assessing suitability for sedation [grade c]
    2. See appendix 4 for patient pathway for ketamine sedation
    3. See appendix 5 for sedation proforma


d. History, contraindications

A full history, including drugs, previous sedation or anaesthesia, allergies and fasting time should be documented. [grade c]
Procedural sedation in the ED is contraindicated if any one of these applies [grade b]

  • Procedures involving stimulation of the posterior pharynx
  • Procedures that are more appropriately performed under general anaesthesia or in sterile operating theatre conditions
  • Patient is ASA grade 3,4 and 5
  • Child less than 12 months
  • History of airway instability, tracheal surgery, or tracheal stenosis or abnormal facial anatomy
  • Active pulmonary infection or disease (including upper-respiratory infection, exception is for asthma)
  • Head injury associated with loss of consciousness, altered mental status, or vomiting
  • Central nervous system masses, abnormalities, or hydrocephalus
  • Poorly controlled seizure disorder
  • Glaucoma or acute globe injury

e. Fasting guidelines

General guidelines for fasting for procedural sedation in the ED [Evidence B]

Oral intake in the last 3 hours

(Life or limb threatening)

(To resolve severe pain)



All levels of sedation

All levels of sedation

All levels of sedation

Clear liquids only


All levels of sedation

Up to and including brief sedation

Minimal sedation only

Light snack

Minimal sedation only*

Minimal sedation only

Minimal sedation only

Heavier snack or meal

Minimal sedation only*

Minimal sedation only

Minimal sedation only

Emergency Situations
NICE recommends that for emergency situations in a patient who has not fasted, base the decision to proceed with sedation on the urgency of the procedure and target depth of sedation2.

The fasting state of the child should be considered in relation to the urgency of the procedure, but recent food intake should not be considered an absolute contraindication to the use of ketamine (CEM Ketamine guideline). [Evidence B]

    f. Consent

  • Written consent to be completed by a senior staff member
  • Both the parent/guardian and child should be involved in the discussion of the treatment advised

2. During Sedation

    a. Patient monitoring [grade c]

  • Close observation of the airway by an experienced health care professional until recovery is well-established
  • Exposure of patient such that airway and chest motion can be visualized at all times
  • Availability of oxygen supplementation with pulse oximetry, capnography, ECG, and BP
  • The routine use of supplemental oxygenation may allow SpO2 to remain satisfactory but hide the fact that there is significant hypoventilation and the patient may be on the cusp of losing their airway. In the absence of end tidal CO2 monitoring, consider supplemental O2 unless signs of hypoventilation or hypoxia (sats <94%). End tidal CO2 and BP should be monitored if possible, provided that monitoring does not cause the patient to awaken and prevent completion of the procedure2
  • Level of consciousness - will need regular communication with the patient to assess.

    b. Monitoring level of consciousness [grade c]

Objective measurements quantifying the depth of sedation have not yet been fully established. Currently, several qualitative tools are used to measure sedation depth.
Although these can be used for documentation of sedation depth no scale can objectively predict deep sedation with subsequent respiratory depression, which is clearly an undesirable endpoint.


  • Procedural sedation should take place in the paediatric resuscitation bay.
  • There should be a tilting trolley, suction, oxygen, and equipment for advanced airway management.
  • Where time permits, topical anaesthesia should be considered to reduce the pain of intravenous cannulation or intramuscular injection.
  • Accredited consultant or PEM HST present.
  • Ketamine sedation requires a minimum of 3 dedicated members of staff, one to undertake sedation, one to monitor the patient and another to undertake the procedure.
  • If appropriate facilities are not available patients should either be brought back for the procedure the next morning (booked into the PEM Clinic) or referred for a general anaesthetic whichever is the most appropriate pathway.

The sedative agent of choice for the majority of procedures in the ED is ketamine due to its excellent safety profile. Clinicians with experience of using alternative drugs may choose these agents for appropriate procedures: [grade B]

The agent of choice if sedation is required for minor procedures in children is IV Ketamine. At Leeds Teaching hospitals a concentration of Ketamine 10mg/mL is used for IV use.
Intravenous sedative/analgesic drugs should be given in small, incremental doses that are titrated to the desired end-point of analgesia and sedation. Initial doses of 0.5-1mg/kg are usually required, additional boluses of 0.25mg/kg may be required. Familiarity with drugs effects and potential side effects is important (appendix 6 for medicine information).

Where IV access is difficult IM ketamine remains an option, it should be reserved for clinicians experienced in its use. IM ketamine has a higher risk of emesis and a longer recovery time. Due to formulations of ketamine available the volume required for IM injection are large meaning injection can be painful. At Leeds Teaching Hospitals 1.5mg/kg S-Ketamine is used as an initial dose. S-Ketamine is a concentration of 25mg/mL.
See appendix 7 for appropriate dosing schedule.

Where possible for painful injuries, sedation should be augmented by local anaesthesia or pre-procedure analgesia for example paracetamol, ibuprofen, and intranasal fentanyl or IV morphine. Opiates should be given at least 10 minutes before sedation to reduce risk of respiratory depression.


Complications Treatment


Adrenaline nebs (5mls of 1:1000); maintain airway with tight fitting mask, consider use of Mapleson C anaesthetic circuit

Hypoxia from respiratory depression (SPo2 < 92%)

Airway adjuncts and support ventilation with BVM.

Hypotension (age specific)

Fluids, Ephedrine, Metaraminol

Bradycardia (age specific)


Increased level sedation

Support airway and call for help

Adverse effects specifically associated with ketamine sedation [grade b]

  • Laryngospasm (see below)
  • Hypersalivation (~10-30%)
  • Emesis (~5-15%)
  • Emergence phenomena such as recovery agitation (10-20%, with 1-2% clinically significant), dreams, hallucinations and depersonalisation
  • Transient respiratory depression (usually in the first 2-3 minutes following a large, rapidly administered IV dose)
  • Transient mild increase in heart rate and blood pressure
  • Evanescent patchy erythematous rash about the upper torso (5-20%)
  • Nystagmus and random purposeless movements while sedated

Emergence phenomena
Clinically significant unpleasant emergence phenomena are best treated with small incremental doses of Midazolam. (0.05-0.1mg/kg midazolam)
Intractable Vomiting
If intractable vomiting occurs post procedure, consider use of IV ondansetron in a dose of 0.1mg/kg (maximum of 4mg) by slow intravenous injection.
Ketamine is known to preserve and exaggerate protective airway reflexes. Laryngospasm is a much feared complication – however, it is extremely rare.
From a 2009 meta-analysis of 32 studies including 8,282 children, Green and colleagues reported a rate of laryngospasm of 0.3% from ketamine sedation. In nearly all cases the laryngospasm was transient and responded to oxygenation and ventilation. Only two children (0.017%) required intubation for laryngospasm [6].

How can laryngospasm be prevented? [grade b]

  • Avoid ketamine sedation in children if:
  • <12 months of age — Very young children have a higher risk of airway problems, laryngospasm and apnoea from all forms of sedation and anaesthesia
  • Active URTI (RR 5.5)
  • Active asthma (RR 3.7)
  • Ensure adequate depth of sedation before commencing the procedure and avoid stimulation of the posterior pharynx.

Management of laryngospasm includes the following:

  • Stop the procedure. Call for expert help. Ensure equipment for difficult intubation is at hand.
  • Administer 100% oxygen through a mask with a tight seal and a closed expiratory valve to try to force the vocal cords open with positive pressure. Hypoxia can occur rapidly in children when ventilation is inadequate.
  • Clear the airway of blood and secretions, if the child is adequately oxygenated.
  • Attempt manual ventilation while continuing to apply continuous positive airway pressure (CPAP).

Recovery area

  • Minimal physical contact or other psychic disturbance. Quiet area with dim lighting if possible
  • Recovery should be complete within 60-120 minutes
  • Advise parents or caretakers not to stimulate patient prematurely
  • Continue oxygen saturation monitoring until alert (or for 30 minutes post IM ketamine injection)
  • Following IV ketamine nursing staff should observe the patient until they are alert.
  • If IM ketamine is used recovery may be slower, after 30 minutes children can be moved to a cubicle to recover. The risk of airway complications is extremely rare at this stage and the child can be allowed to recover.


  • Recovery time depends on drug(s) used
  • Awake, able to move all 4 limbs voluntarily or on command, able to breathe and cough freely, able maintain Oxygen saturation >94% on room air and BP± 20 mm of Hg of pre-sedation level
  • Ability to take oral fluids.
  • Give discharge instructions (see advice sheet):Restricting food for 2 hours (due to risk of nausea and vomiting)


The use of these techniques to deliver moderate/dissociative or deep sedation to children within the ED is restricted to Emergency Medicine Consultants who have attained the relevant competencies.
All clinicians should be thoroughly conversant with this guideline before delivery of a sedation service.
For ketamine sedation an accredited clinician should be present to assess the competence of clinical staff in training prior to being accredited as competent (see appendix 7 which outlines the training competencies and relevant work based assessment requirements).

Healthcare professionals delivering sedation should have the following

Knowledge and understanding of
and competency in:

Practical experience of:

Documented up-to-date evidence
of competency including:

Sedation drug pharmacology and
applied physiology

Effectively delivering the chosen
sedation technique and
managing complications

Satisfactory completion of a
theoretical training course
covering the principles of
sedation practice

Assessment of children and
young people

Observing clinical signs
(for example, airway patency,
breathing rate and depth, pulse,
pallor and cyanosis, and depth
of sedation)

A comprehensive record of
practical experience of sedation
techniques, including details of:
– sedation in children and
young people performed
under supervision
– successful completion of
work-based assessments


Using monitoring equipment.


Recovery care



Complications and their
immediate management,
including paediatric life support



Members of the sedation team should have the following life support skills


Minimal sedation, sedation with nitrous oxide alone (in oxygen)

Moderate sedation

Deep sedation/Dissociative drugs

All members




At least one member




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Record: 2774

This guideline is to help Emergency department clinicians safely deal with children and younger people who need procedures requiring sedation in the ED e.g. joint reduction, fracture manipulation, and suturing.

This guideline should not be used outside of the ED resuscitation room.

Sedation covers the continuum from mild to deep sedation and also the state of dissociation produced by ketamine.

Objectives: To ensure that:

  • All children undergo a process of appropriate pre-sedation assessment with the appropriate documentation of this assessment
  • The assessment will judge the suitability for sedation and whether more appropriate methods to perform a procedure should be used e.g. local infiltration, general anaesthetic
  • Appropriate information is supplied to the child and parents to enable them to make an informed choice about the procedure
  • Healthcare professionals are appropriately supervised and trained while attaining paediatric sedation competencies
  • The appropriate monitoring, and staffing is available prior to initiation of sedation
  • The appropriate drug is selected to successfully perform the procedure while having a wide safety margin to minimize complications
Clinical condition:


Target patient group: Children and younger people within the ED
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. Boyle, A., et al., Sedation of children in the emergency department for short painful procedures compared with theatre, how much does it save? Economic evaluation. Emergency Medicine Journal, 2011. 28(5): p. 383-386.
  2. National Institute for Health and Clinical Evidence, Sedation in children and young people, 2010, London: National Institute for Health and Clinical Evidence.
  3. Green, S.M., et al., Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of Emergency Medicine, 2011. 57(5): p. 449-461.
  4. McGlone, R., et al., A comparison of intramuscular ketamine with high dose intramuscular midazolam with and without intranasal flumazenil in children before suturing. Emergency Medicine Journal, 2001. 18(1): p. 34-38.
  5. McGlone, R.G., M.C. Howes, and M. Joshi, The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emergency Medicine Journal, 2004. 21(3): p. 290-295.
  6. Green, S.M., et al., Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children. Annals of Emergency Medicine,2009. 54(2): p. 158-168.

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Appendix 1: Abbreviation list

ASA-American Society of Anaesthesiologists
CEM-College of Emergency Medicine
ED- Emergency Department
NICE-National institute of clinical effectiveness
QIPP-quality, innovation, prevention, productivity

Appendix 2 - American Society of Anesthesiologists (ASA) physical status grade

  1. Healthy patient. Localised surgical pathology with no systemic disturbance.
  2. Mild to moderate systemic disturbance (the surgical pathology or other disease process) No activity limitation.
  3. Severe systemic disturbance from any cause. Some activity limitation.
  4. Life-threatening systemic disorder. Severe activity limitation.
  5. Moribund patient with little chance of survival.

Appendix 3: Sedation score/Pain score

  1. Co-operative /unreactive
  2. Intermittent crying
  3. Continuous crying
  4. Uncontrolled crying

Pain score

  1. I don’t hurt at all
  2. It hurts just a little bit
  3. Some hurt
  4. It hurts a lot
  5. The hurt is the worst I’ve ever had

Appendix 4: Patient pathway for ketamine

Appendix 5: Emergency Department Paediatric Sedation Proforma

Appendix 6: Ketamine for intravenous sedation use

Ketamine is administered as a 10 mg/ml solution. Initial bolus of 0.5-1 mg/kg should be administered slowly over a minute. i.e for a 40 kg child 2-4 ml of solution should be administered. Additional boluses of ~0.25 mg/kg should be given i.e. 10 mg or 1 ml.

Appendix 7: Ketamine dose/weight chart for IM ketamine

The dose recommended by Green suggests 4 mg/kg as an IM dose [3], a lower initial dose has been used to reliable effect in various studies and may lower the complication rate [4, 5]. As a result of supply problem of 100 mg/ml racemic ketamine, the ED has switched to S-ketamine 25 mg/ml solution for IM administration only. S-ketamine is roughly 1.7 times more potent, with possibly less side effects. We are using 1.5 mg/kg for initial dose with 1 mg/kg for supplemental doses.
S-KETAMINE 25 mg/ml solution for IM use in children
S-ketamine is supplied in 2 ml ampoules (50 mg/ampoule)


Dose (mg) 1.5 mg/kg

Volume (ml)*

Additional top up dose
1 mg/kg

Additional top up volume (ml)




10 mg





11 mg





12 mg





13 mg





14 mg





15 mg





16 mg





17 mg


*Dose rounded down to 1 ml as max volume in syringe.

An additional top up dose should be administered as 1 mg/kg.
Example a 10 kg child would receive 15 mg (0.6 ml) for the initial dose and 10 mg (0.4 ml) for the top up dose.

Because injection of more than 1 ml IM is painful, then children larger than 17 Kg should have IV ketamine if sedation is required for painful procedures.


Appendix 8: Competency Framework for Paediatric Sedation using Ketamine in the Emergency Department

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